Onycholysis as a complication of systemic chemotherapy: report of five cases associated with prolonged weekly paclitaxel therapy and review of the literature

BACKGROUND

Onycholysis has been reported in association with the use of several noncytotoxic drugs and with chemotherapy in 135 patients. Onycholysis may be precipitated by exposure to ultraviolet radiation.

METHODS

The authors studied 91 patients who received paclitaxel and 187 patients who received doxorubicin.

RESULTS

Onycholysis occurred in 5 of 21 patients who received > 6 courses of weekly paclitaxel, developing in the summer months in all 5 patients. It did not occur in patients who received fewer weekly paclitaxel courses or those who were treated every 3 weeks. Onycholysis did not occur in 187 patients who received doxorubicin. Review of the literature revealed that onycholysis is nearly exclusively associated with anthracycline and taxane therapy.

CONCLUSIONS

Prolonged weekly paclitaxel, other taxanes, and anthracyclines cause onycholysis in some patients, which may be precipitated by exposure to sunlight. Patients receiving these drugs should protect their nails from sunlight.

Treating depression in old age: the reasons to be positive

Depression affects 10-15% of people over 65 living at home in the United Kingdom. It is the commonest and the most reversible mental health problem in old age. Depression is associated with physical illness and disability, life events, social isolation and loneliness. Depression in old age carries an increased risk of suicide and natural mortality. Recognition and simple intervention can reduce morbidity, demand on health and social services and the cost of community care. Despite a favourable response to treatment, depression remains largely undetected and untreated.

The delusion of inanimate doubles. Implications for understanding the Capgras phenomenon

The Capgras delusion has long been held to be specific for close personal relationships. This paper presents evidence that this is not the case and the implications of this for accepting psychodynamic explanations of the phenomenon are discussed. Parallels are drawn with the condition prosopagnosia and a hypothesis presented that any specificity is apparent rather than real. It is proposed that both prosopagnosia and the Capgras symptom represent abnormalities of visual perception occurring at different stages of this neurophysiological process.

Domiciliary clinics I: effects on non-attendance

OBJECTIVE

To compare the rate of non-attendance for new referrals to a hospital based clinic versus home assessment.

SETTING

Two old age psychiatry services in an urban area.

METHOD

A four year prospective study comparing rates of non-attendance for new referrals to a hospital based clinic versus assessment at home in two parallel old age psychiatry services.

RESULTS

The rate of non-attendance for new referrals seen at home was considerably lower (1.7%) than the hospital based clinic (21.2%).

CONCLUSIONS

Assessing new outpatient referrals to old age psychiatry services at home reduces non-attendance. This improves efficient use of medical time in a small geographical catchment area but may not apply to rural or larger areas.

Accuracy of laparoscopic ultrasonography in the staging of upper gastrointestinal malignancy

Laparoscopic ultrasonographic staging was compared prospectively with conventional computed tomography (CT) and ultrasonographic staging of 24 lower-third oesophageal tumors and 20 gastric malignancies. Following laparoscopic ultrasonography, seven patients regarded as being resectable after conventional imaging were excluded from surgical exploration because of ascites with peritoneal deposits (four patients), liver metastases (one), advanced local disease (one) and poor tolerance of general anaesthesia (one). Preoperative T and N stages were compared with the pathological staging following resection in 34 patients. Laparoscopic ultrasonography was significantly more accurate than conventional CT and ultrasonography in assessment of the primary tumour (91 versus 64 per cent, P < 0.01) and nodal status (91 versus 62 per cent, P < 0.05). The addition of laparoscopic ultrasonography to conventional procedures for staging upper gastrointestinal malignancy improved the overall accuracy of staging. Although this may have future implications for the selection of patients for multimodality treatment, management decisions are currently based on laparoscopic findings, which in this study resulted in a resection rate of 97 per cent.

Recovery from depression after electroconvulsive therapy is accompanied by evidence of increased tetrahydrobiopterin-dependent hydroxylation

Serum phenylalanine and tyrosine levels were measured in 26 patients with severe depression before and after receiving electroconvulsive therapy. The phenylalanine:tyrosine [P:T] ratio declined significantly for those responding to treatment but not for nonresponders. These findings are discussed in relation to tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, dopamine and serotonin and the hydroxylation of phenylalanine to tyrosine.

Koro: the genital retraction symptom after stroke

The complete Koro complex in an elderly male Briton was associated with psychotic depression following a non-dominant temporoparietal stroke. As Koro lacks both cultural and diagnostic specificity, it would be more appropriately renamed the genital retraction symptom.

The role of pterins in depression and the effects of antidepressive therapy

Urinary excretion of neopterins (N) and biopterins (B) was measured in 48 patients with depression before and after treatment with placebo, antidepressants, or electroconvulsive therapy (ECT), and in 26 healthy control subjects. Patients prior to and after treatment had a significantly greater neopterin/biopterin (N:B) ratio than control subjects. There was a significant correlation between N:B ratios and the severity of depression and plasma cortisol. As a raised N:B ratio implies failure to convert neopterin to biopterin, it is possible that reduced availability of tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, serotonin and dopamine, may exert rate-limiting control over the synthesis of monoamines implicated in the pathogenesis of depressive illness.

Secondary perineal hernia following open abdominoperineal excision of the rectum: report of a case and review of the literature

This is a case report of a 46-year-old man who presented with a painful perineal lump four months after abdominoperineal excision of the rectum (APER) with pre-operative radiotherapy and adjuvant chemotherapy. Perineal hernia (suspected clinically) was confirmed by magnetic resonance imaging, and the patient underwent open Permacol mesh repair via a perineal approach. Symptomatic perineal herniation after surgical resection is a rare phenomenon, and the approach to management remains challenging. Several different surgical approaches and techniques of repair have been described. In this report, we review the literature surrounding the presentation, aetiology and repair of this unusual post-operative complication. Furthermore, our case confirms that closure of the hernial orifice with mesh via a perineal approach is a satisfactory technique.

Maintenance electroconvulsive therapy and cognitive function

BACKGROUND

ECT is rarely used as a prophylactic treatment. A 74-year-old woman with unstable bipolar affective disorder receiving maintenance ECT presented a unique opportunity to measure the cognitive effects of continuing ECT.

METHOD

A single case report with serial psychometric testing during over 400 ECT treatments as a single maintenance treatment.

RESULTS

Serial testing did not demonstrate progressive cognitive deterioration, but consistent cognitive deficits typical of acute treatment were evident. The degree of cognitive difficulty may be related to the frequency of treatment.

CONCLUSIONS

Maintenance ECT can be an effective prophylactic treatment for selected patients. Cognitive effects would appear to be no greater than with acute treatment and seem to be non-progressive.

Pterin metabolism in depression: an extension of the amine hypothesis and possible marker of response to ECT

Urinary excretion of neopterins and biopterins was measured in 23 patients with severe depression before and after receiving electroconvulsive therapy (ECT) and 26 healthy control subjects. Patients with psychotic depression and those responding to ECT had neopterin:biopterin (N:B) ratio significantly higher than controls before commencing ECT and positive therapeutic response was associated with reduction of N:B ratio towards control values. As a raised N:B ratio implies failure to convert neopterin to biopterin it is possible that reduced availability of tetrahydrobiopterin, the essential cofactor for the formation of noradrenaline, serotonin and dopamine, may exert rate limiting control over the synthesis of monoamines implicated in the pathogenesis of depressive disorders. The N:B ratio may be a marker for certain depressive subtypes and response to ECT.

A comparison of in-patient and out-patient prescribing

The prescribing of psychotropic medication to 96 attenders at a lithium clinic was compared with their prescriptions while in-patients. As out-patients, they received fewer psychotropic drugs fewer times a day. This suggests that psychiatrists do not adopt intransigent stances in favour of polypharmacy and irrational psychotropic prescribing, as previous studies have implied. Caution is advised before attributing apparently irrational prescribing to bad clinical practice, or advocating remedial action aimed at changing the habits of prescribers.

A retrospective evaluation of automated optimization of deep brain stimulation parameters

OBJECTIVE

We performed a retrospective analysis of an optimization algorithm for the computation of patient-specific multipolar stimulation configurations employing multiple independent current/voltage sources. We evaluated whether the obtained stimulation configurations align with clinical data and whether the optimized stimulation configurations have the potential to lead to an equal or better stimulation of the target region as manual programming, while reducing the time required for programming sessions.

APPROACH

For three patients (five electrodes) diagnosed with essential tremor, we derived optimized multipolar stimulation configurations using an approach that is suitable for the application in clinical practice. To evaluate the automatically derived stimulation settings, we compared them to the results of the monopolar review.

MAIN RESULTS

We observe a good agreement between the findings of the monopolar review and the optimized stimulation configurations, with the algorithm assigning the maximal voltage in the optimized multipolar pattern to the contact that was found to lead to the best therapeutic effect in the clinical monopolar review in all cases. Additionally, our simulation results predict that the optimized stimulation settings lead to the activation of an equal or larger volume fraction of the target compared to the manually determined settings in all cases.

SIGNIFICANCE

Our results demonstrate the feasibility of an automatic determination of optimal DBS configurations and motivate a further evaluation of the applied optimization algorithm.

The delusion of inanimate doubles

A review of new cases of delusional misidentification reported between 1986 and 1992 suggests that the delusion of inanimate doubles is a variant of the Capgras phenomenon in approximately 10% of cases. It is argued that this variant makes current psychological theories of misidentification untenable.

Does age predict the long-term outcome of depression treated with ECT? (a prospective study of the long-term outcome of ECT-treated depression with respect to age)

Sixty-three subjects with DSM-III-R major depression with melancholia or psychosis were followed up 2-4 years after index treatment with electroconvulsive therapy. There was a twofold increase in likelihood of improved outcome with an additional 20 years of age.

Basic Surgical Training in the Era of the European Working Time Directive: What are the Problems and Solutions?

Background and Aims

Imposed reductions in working hours will impact significantly on the ability of surgical trainees to achieve competency. The objective of this study was to obtain the opinions of Scottish surgical trainees concerning the training they receive, in order to inform and guide the development of future, high-standard training programmes.

Methods

An anonymous questionnaire was sent to basic surgical trainees on the Edinburgh, Aberdeen and Dundee Basic Surgical Rotations commencing after August 2002.

Results

Thirty six questionnaire responses were analysed. Very few of the returned comments were complimentary to the existing training structure; indeed, most comments demonstrated significant trainee disappointment. Despite “regular” exposure to operative sessions, training tutorials and named consultant trainers, the most common concern was a perceived lack of high-quality, structured, operative exposure and responsibility. Textbooks and journals remain the most frequently utilised learning tools, with high-tech systems such as teleconferencing, videos, CD-ROMS, and DVDs being poorly exploited.

Conclusions

Current surgical training is not meeting the expectation of the majority of its trainees. To solve this problem will require extensive revision of attitudes and current educational format. A greater emphasis on the integration of 21st century learning tools in the training programme may help bridge this gap.

Experimental mycosis in immunosuppressed rabbits. II. Acute and chronic aspergillosis

The influence of immunosuppression on the course of experimental aspergillosis was investigated. Rabbits (2.2--2.5 kg) were divided into four groups. Group one received no drugs and was given 10(6) spores intravenously (IV) or intratracheally (IT) on two occasions one week apart. Weight gain or loss, appearance or disappearance of aspergillus antigen and/or antibody, and detection of aspergillosis at autopsy were followed. Group 2 received weekly injections of cyclophosphamide (70 mg/kg) starting two weeks prior and throughout the experiment. Animals in group three received either 1.14 or 2.25 mg/kg/day methyl prednisolone and group four received 2.28 mg/kg/day methyl prednisolone and 70 mg/kg/week cyclophosphamide. In group one, serum antigen levels were detected within a week of infection followed by antibody (I.D.) levels for three months. All animals grew normally and no infection was detected at autopsy. In group 2, animals survived one but not two challenges and had Ag but no Ab. In group 3, animals survived two challenges at the lower drug level but not the higher. All animals in group 4 succumbed to one challenge.

Loop ileostomy fixation: a simple technique to minimise the risk of stomal volvulus

Turnbull's "loop" ileostomies is a routinely performed procedure in the management of a variety of colorectal problems. Mechanical and functional complications occur with both permanent and temporary ileostomies, however they are more common with the loop than with the end (Brooke) variety. With the advent of restorative proctocolectomy with pouch formation, and the documented benefit of simultaneous temporary faecal diversion, the incidence of such complications will rise. Bowel obstruction, requiring laparotomy in the interval before stoma closure, is more commonly associated with the loop ileostomy. A loop stoma is routinely brought out directly through the abdominal wall, with little or no fixation or closure of the lateral space. However, anti-mesenteric fixation, as described here, minimises the risk of volvulus by widening the attachment of the adjacent ileum to the parities, creating a broader fulcrum. Since adopting this simple technique, we report no complications in over 30 loop ileostomies, "fixed" by this technique and followed up for a minimum of 4 years. Where applicable, no difficulty was encountered with stoma closure, either by a transverse single layer serosubmucosal technique, or as a minimal resection with end to end anastomosis (sewn or stapled), following bowel mobilisation. This technique should minimise the frequency of obstructive events, and we recommend it's routine use.

5-Methyltetrahydrofolate level in the serum of depressed subjects and its relationship to the outcome of ECT

Serum 5-MeTHF levels are reported in 26 subjects, before and after completing a course of ECT, and compared to 21 healthy volunteers. 5-MeTHF levels of depressed subjects were significantly lower than controls before and after ECT. There was no difference in 5-MeTHF levels between ECT responders and non-responders but folate deficiency was related to severity of depression before ECT. Serum 5-MeTHF was not related to treatment response and values remained markedly low even after a good response to treatment.

Chicken or the leg: Sigmoid colon perforation by ingested poultry fibula proximal to an occult malignancy

INTRODUCTION

Colonic perforation by ingested foreign bodies is exceedingly rare, with the diagnosis made more challenging by patients infrequently recalling any inadvertent ingestion and the poor sensitivity of plain radiography.

PRESENTATION OF CASE

The presented case demonstrates that bony perforation of the large bowel might occur immediately proximal to an otherwise occult colonic malignancy.

DISCUSSION

Ingestion of foreign bodies is common and rarely results in colonic perforation. However, bony ingestion is not usually remembered and can be missed even with cross-sectional imaging. If present, consideration should be given to the presence of an adjacent concealed colon cancer.

CONCLUSION

The co-existence of separate pathology should be carefully assessed in these patients, since this has important implications for relevant investigations and appropriate surgical management.

Experimental mycosis in immunosuppressed rabbits. I. Acute and chronic candidosis

Chronic candidosis was established in rabbits by the injection I.V. of 2 X 10(6) cells of C. albicans. The rabbits were assayed every week for 14 weeks for the appearance of candida antigen and anticandida antibodies in serum and other body fluids. Tests were carried out in double diffusion plates; antigen against hyperimmune rabbit sera and antibody against Candida cell sap antigen preparation. A sensitive specific passive hemagglutination procedure was also developed which used chromate treated cells. In rabbits with chronic candidosis not treated with cyclophosphamide antigen was detected in 4x concentrated serum between the fifth and sixth week. At about the same time antibodies were demonstrable and thereafter antigen was no longer detected. Maximum antibody titer occurred between the eight to 10th week and disappeared thereafter. If cyclophosphamide 30 mg/kg was given at this point, anticandida antibodies reappeared in high titers, persisted from three to four weeks and then disappeared. At autopsy no evidence of candidosis was present. If rabbits were pretreated with cyclophosphamide 60 mg/kg for one week before inoculation and given the drug weekly thereafter no antibody was detectable but antigen and antibody were present in body fluids (not serum) at post mortem.

Paraileostomy recontouring by collagen sealant injection: a novel approach to one aspect of ileostomy morbidity. Report of a case

INTRODUCTION

Poorly fitting stoma appliances, resulting in stomal leakage and subsequent skin excoriation, remain a significant cause of ileostomy-related morbidity. One cause of ill-fitting stoma bags is the presence of parastomal dermal contour defects/irregularities. These may occur after surgical complications or change in patient weight and body habitus.

METHODS

We report the case of a 29-year-old man who, after panproctocolectomy and formation of ileostomy for ulcerative colitis, experienced significant problems with stoma bag application because of dermal contour defects. As a result, he suffered from significant stomal leakage and skin excoriation. After a single treatment of cutaneous parastomal infiltration of porcine collagen (Permacol Injection), applied stoma bags achieved a watertight seal, and the patient experienced complete and sustained resolution of his symptoms.

CONCLUSIONS

Porcine collagen is a safe, versatile, and relatively easy method of restoring irregular skin defects surrounding abdominal stomas, thus resolving the significant patient morbidity associated with ill-fitting stomal appliances. Such a technique avoids the need for surgical stoma refashioning, which may be associated with significant morbidity and unsatisfactory outcomes.